The Adolescent Health Guide is designed for
healthcare providers, social workers, counselors, teachers, and other
professionals who provide services, information, and support to young people.
It offers guidelines on health and health-related legal issues pertinent to the
adolescent years. For specific concerns or questions regarding state or federal
law, it is recommended that you seek advice from legal counsel, your licensing
board, the local school district, or other applicable state agencies.Information in
this guide is current as of January 2016.
Many legal
requirements regarding health-related issues apply to minors. In Texas, a minor
is a person under 18 years of age who has never been married and never been
declared an adult by a court (emancipated). Texas
Family Code §§101.003; 31.001-31.007; 32.003-004; 32.202; Texas Civil Practices
& Remedies Code §129.001
Adolescence is not “one size fits all.” There are three recognized developmental
stages. Keep in mind that an adolescent’s physical, intellectual, and social
maturity may not be synchronized at all stages.
STAGES OF ADOLESCENCE:
EARLY ADOLESCENCE
Growth spurt
Signs of sexual
maturation
Concrete thinking
but without consistent ability to process consequences of actions
Initial
development of abstract thought
MID-ADOLESCENCE
Physical pubertal
changes stabilizing
Growing sense of
identity
Progress in
developing reflective thought
Peer
relationships and risk- taking more prominent
LATE ADOLESCENCE
Physically adult
form
Set sense of
identity
More mature
relationships
Transition to
living away from family
In the transition
from childhood to adulthood, adolescents develop new health care needs and
concerns at the same time they are gaining autonomy from their parents. They
progress from gradually becoming active participants in their health care to
being the primary partner in medical decision-making. Building a strong
therapeutic alliance with young people can help them become responsible health
care decision-makers.
Parents do not
suddenly relinquish medical decision-making to their children. They are a vital
part of this process. The process itself must be construed within the framework
of consent and confidentiality laws.
DECISION-MAKING / TRANSITION FROM CHILDHOOD
TO ADULTHOOD
Parent / Doctor
(early adolescence)
Parent / Patient
/ Doctor (mid-adolescence) Patient / Doctor (late adolescence)
PARENTAL CONSENT TO MEDICAL CARE
Parents have the
right to consent to their minor child’s medical and dental care. (Texas Family
Code §151.001)
WHEN PARENTS ARE DIVORCED
Either parent can
give consent for any emergency health care, including surgical procedures.
Sole managing
conservator parents may give consent for a minor’s non-emergency surgical
procedure.
Joint custodial
parents may have all rights associated with a managing conservator, unless
specifically limited by the divorce decree.
Non-custodial
parents usually have the right to consent for medical/ dental care not
involving a surgical procedure, except in an emergency.
Non-parent sole managing conservators and
legal guardians have essentially the same rights and duties as parent
sole-managing conservators.
Note: For emergency treatment to preserve life and
limb, a provider does not need the consent of a parent or conservator. (Texas
Family Code §33.001 and Texas Health and Safety Code §171.002)
A parent must
consent to immunizations of a minor. A child may consent to the child’s own
immunization for a disease if the child is 1) pregnant or is the parent of a
child and has actual custody of that child; and 2) the Centers for Disease
Control and Prevention recommends or authorizes the initial dose of an
immunization for that disease to be administered before seven years of age.
(Texas Family Code §§32.003; 32.101; and Health and Safety Code §773.008)
Consent and
access to information by divorced parents are covered by Texas Family Code
§§153.073–.074; 153.132; Texas Occupations Code §159.005.
For more
information about consent issues, see the Texas Health Steps Online Provider
Education module Teen Consent and
Confidentiality. www.txhealthsteps.com
A minor parent
can consent to immunizations for his or her own child. (Texas Family Code
§§32.101; 32.003; and Health and Safety Code §773.008)
WHEN MINORS CAN CONSENT
MINORS CAN CONSENT TO TREATMENT BY A
PHYSICIAN OR DENTIST WHEN THE MINOR IS:
On active duty
with armed services.
16 years old or
older and residing apart from parents, managing conservator or guardian and
managing his or her own financial affairs.
Unmarried and
pregnant and consenting to treatment related to pregnancy other than abortion.
Unmarried and the
parent of a child and has actual custody of that child and consents for
treatment of the child.
Consenting to
diagnosis or treatment of an infectious, contagious, or communicable disease
that is reportable to the Texas Department of State Health Services.
Consenting to
examination or treatment for chemical addiction, dependency, or any other
condition directly related to chemical use.
Consenting for
counseling for suicide prevention, chemical addiction or dependency, or for
sexual, physical, or emotional abuse.
(Texas Family
Code §§32.003-004)
Notes: For inpatient mental health treatment: A
person age 16 or older, or a person younger than 16 who is or has been married,
may give consent when requesting admission to an inpatient mental health
facility by filing a request with the administrator of the facility. (Texas
Health and Safety Code §572.001)
Instances in
which a minor may consent to emergency shelter or care are covered in Texas
Family Code §32.202 and Texas Health and Safety Code §773.008. Notification
requirements are found in Texas Family Code §33.0022.
CONSENT BY A NON-PARENT
THE FOLLOWING
INDIVIDUALS MAY CONSENT to health care treatment of a minor (other than
immunization) when a parent or conservator cannot be contacted and that person
has not given express notice to the contrary:
Grandparent,
adult brother or sister, or adult aunt or uncle of the minor.
Adult who has
actual care, control, and possession of the minor and has written authorization
to consent from a person having the right to consent.
Adult responsible
for the actual care, control, and possession of a minor under the jurisdiction
of a juvenile court or committed by a juvenile court to the care of an agency
of the State or County.
Court having
jurisdiction over a suit affecting the parent-child relationship of which the
minor is the subject.
Educational
institution in which the child is enrolled that has received written
authorization to consent from a person having the right to consent.
Peace officer in
lawful custody of a minor if the peace officer has reasonable grounds to
believe the minor is in need of immediate medical treatment.
The Texas
Juvenile Justice Department (TJJD) facility in which the minor is committed
when the person having the right to consent has been notified and that person
has not given actual notice to the contrary; or, the person having the right to
consent cannot be contacted and the youth’s health care need constitutes a
medical emergency for a life- threatening condition. When the provider
determines a youth needs a diagnostic or treatment procedure or treatment for a
serious injury or illness that requires parental or guardian consent, the
parent or guardian will be contacted to provide written or verbal consent
directly to the medical provider. If the parent or guardian cannot be
contacted, the facility administrator has the authority to consent for
treatment of the youth under certain conditions pursuant to Texas Family Code
§32.001. If a parent or guardian objects to TJJD having medical consent
authority, the parent or guardian will provide written consent for routine
physical, dental, mental health, and chemical dependency examinations or
evaluations and certain immunizations required by law. When a youth is
temporarily admitted to a facility of the Texas Department of State Health
Services, the TJJD medical director may consent to the specific care outlined
in §380.9183 of the TJJD General Administrative Policy Manual if the parent or
guardian cannot be contacted directly for consent. (Texas Family Code §32.001;
TJJD General Administrative Policy Manual §§380 and 9181)
Note: For state law on consent to immunization for
minors and non-parents, see Texas Family Code §§32.101–.102.
CONFIDENTIALITY
Sensitive
communication and assurance of confidentiality are critical to ensuring access
to care for teens. Without such assurance, teens can be reluctant or unwilling
to seek health care or refuse services. Except as permitted by law, a doctor is
legally required to maintain the confidentiality of care provided to a minor.
If a provider has agreed to treat a minor confidentially based on the minor’s
own consent, the doctor should not write or call the parent or guardian to
discuss any related issues.
Transmission of
medical records to the minor should be marked “confidential.” (Texas
Occupations Code §159)
Limitations: Confidential care cannot be provided when
the law requires parental notification or consent or when the law requires the
provider to report health information. A licensed physician, dentist, or
psychologist may, with or without the consent of a child who is a patient,
advise the parents, managing conservator, or guardian of the child of the
treatment given to or needed by the child. (Texas Family Code §32.003)
Note: Providers must have a responsible adult, a
parent, guardian, or other authorized adult present during any Texas Health Steps
medical or dental checkup for patients younger than 15 years old. The
responsible adult must come with the patient and stay throughout the checkup.
School health clinics are exempt if the clinic has received consent from the
parent or guardian within the year prior to the visit. (Human Resources Code
§§32.024(s)-(s-1) and 25 Texas Administrative Code §33.6)
For more
information about confidentiality issues, see the Texas Health Steps Online
Provider Education module titled Teen
Consent and Confidentiality. www.txhealthsteps.com
HIPAA PRIVACY RULE
The Health
Insurance Portability and Accountability Act (HIPAA) requires a covered entity
to treat a “personal representative” the same as the individual with respect to
the use and disclosure of the individual’s protected health information.
Generally, parents are the personal representatives for their minor children
and can exercise individual rights, such as access to medical records, on
behalf of their minor children.
EXCEPTIONS: MINORS ARE TREATED AS
“INDIVIDUALS” UNDER HIPAA WHEN:
The minor obtains
care without parental consent and the minor, a court, or someone else has
consented;
The minor has the
right to consent and has consented; or,
A parent consents
to a confidentiality agreement between the minor and the health- care provider.
(45 Code of
Federal Regulations §164.504)
For more
information about the HIPAA privacy rule, see the Texas Health Steps Online
Provider Education module titled Teen Consent
and Confidentiality. www.txhealthsteps.com
NUTRITION
During medical
checkups:
Assess dietary
practices to identify eating habits or possible eating disorders.
Make a
qualitative/quantitative determination about the adolescent’s diet.
Provide health
education and anticipatory guidance.
DISORDERED EATING
With disordered
eating, physical hunger and satiety are often ignored. It encompasses a range
of abnormal eating, including behavior seen in eating disorders, such as:
Anorexia, Chronic restrained eating, Bulimia, Habitual dieting, Compulsive
eating, Irregular, chaotic eating patterns
Disordered eating
negatively affects overall health – emotional, social, and physical. It may
cause tiredness, depression, and decreased mental functioning and
concentration. Disordered eating may also lead to malnutrition, with risk to
bone health, physical growth, and brain development.
For information
on nutrition and disordered eating, see the Texas Health Steps Online Provider
Education modules titled Nutrition and
Management of Overweight and Obesity in
Children and Adolescents. www.txhealthsteps.com
ORAL HEALTH
Tooth decay is
the most common chronic childhood disease. Focusing on oral health during
adolescence is important, as many childhood risk factors persist and new oral
health risk factors may emerge. An oral examination should be a part of all
routine medical checkups and physical examinations. At this time, providers
have the opportunity to educate their patients about good oral health practices
and provide information about oral health risks due to smoking, poor eating
habits, and other behaviors.
AN ORAL EXAMINATION SHOULD INCLUDE:
Inspection of
teeth for signs of caries.
Inspection of the
oral soft tissues for any abnormalities.
Referral to a
dentist if problems exist.
Anticipatory
guidance to include:
The need for
thorough daily oral hygiene practices.
Potential
gingival manifestations for patients with diabetes and those under long-term
medications therapy.
For more
information on oral health, see the Texas Health Steps Online Provider
Education module titled Oral Health for
Primary Care Providers. www.txhealthsteps.com
HIGH-RISK BEHAVIORS
Adolescence can
bring an increased participation in high-risk behaviors. The leading causes of
adolescent mortality are accidents, homicide, and suicide. Healthcare providers
and other professionals should communicate openly that they have a suspicion or
concern about a young person’s behavior. Young people engaging in high- risk
behaviors need to get help as soon as possible.
HIGH-RISK BEHAVIORS PREVALENT IN ADOLESCENTS
Reckless driving
Distracted
driving
Violence
Suicidal and
self-injurious behaviors
Sexual behaviors
Substance use
Disordered eating
Poor nutrition
Inadequate
physical activity
For more
information about adolescent high-risk behaviors, see the Texas Health Steps
Online Provider Education modules titled Adolescent
Health Screening, Interpersonal Youth
Violence, and Identifying and
Treating Young People with High-Risk Behaviors as well as Motivational Interviewing. www.txhealthsteps.com
ALCOHOL AND SUBSTANCE ABUSE
The CRAFFT
questionnaire was designed specifically to screen adolescents for substance
abuse. A positive answer to two or more of the questions indicates the need for
intervention.
THE CRAFFT QUESTIONNAIRE:
C Have you ever been in a Car driven by someone, including yourself, who was high or had been
using alcohol or drugs?
R Do you ever use alcohol or drugs to Relax, feel better about yourself, or
fit in?
A Do you use alcohol or drugs while you are by
yourself, Alone?
F Do you ever Forget things you did while using alcohol or drugs?
F Do your family members or Friends ever tell you that you should
cut down on your drinking or drug use?
T Have you ever been in Trouble while
using alcohol or drugs?
MINOR CONSENT FOR CHEMICAL ADDICTION
Minors of any age
may consent to examination or treatment for chemical addiction, dependency, or
any other condition directly related to chemical use. Minors may consent to
counseling for chemical addiction or dependency. (Texas Family Code
§§32.003-.004)
Note: Outreach, Screening, Assessment, and Referral (OSAR) is a free service
funded by DSHS. All Texas residents seeking substance abuse services and
information may qualify.
Statewide online
locator for OSAR providers: http://www.dshs.texas.gov/sa/OSAR/
Statewide
hotline: (877) 9-NO DRUG or (877) 966 -3784.
For more
information on screening adolescents for substance abuse, see the Texas Health
Steps Online Provider Education modules titled Teen Consent and Confidentiality, Identifying and Treating Young People with High-Risk Behaviors, Adolescent Substance Use, Adolescent Health Screening and Introduction to Screening: Brief
Intervention and Referral to Treatment (SBIRT). www.txhealthsteps.com
SMOKING
Medical and
non-medical staff can support patients who choose to quit by providing
information, referral to telephone counseling services, and behavioral
counseling using motivational interviewing techniques, where resources permit.
Drug therapy to manage nicotine dependence can significantly improve patients’
chances of quitting successfully and is recommended for people who smoke 10 or
more cigarettes per day. All interventions should be tailored to the
individual’s circumstances and attitudes.
ADOLESCENTS AND SMOKING
A person must be
at least 18 years old to smoke tobacco legally.
Counseling
adolescents to not smoke or to quit smoking for health-related reasons is an
important component of health education and anticipatory guidance.
All young people
need access to smoking cessation programs, especially medically fragile teens,
who are at higher risk than their peers for smoking-related complications.
Caution youth
about the dangers of e-cigarettes. (Texas Health & Safety Code §161.252)
International
Primary Care Respiratory Group (IPCRG)(2008) Consensus statement: Tackling the
smoking epidemic-practical guidance for primary care. Primary Care Respiratory
Journal, 17(3): 185-193.
Visit http://www.cdc.gov/media/release/2016/p0425-ecigarette-ads.html
for more information about
e-cigarettes.
SEXUAL ACTIVITY
Research* has
found that more than 41 percent of young people engage in sexual activity with
no indication they had any discussion with their parents about sexually transmitted
infections (STIs), condom use, or birth control.
REPORTABLE COMMUNICABLE DISEASES
•Minor Consent - Minors
may consent to diagnosis and treatment of STIs, which are required to be
reported to the local health officer or DSHS. (Texas Family Code §32.003)
•Reporting
Requirements - Providers must report diagnoses of STIs, in addition to other
communicable diseases, to the appropriate health authorities. (Texas
Administrative Code §97.133; Texas Health and Safety Code §§81.41; 81.046)
Note: For more information on sexual activity-related issues, see the Texas
Health Steps Online Provider Education modules titled Adolescent Health Screening, Identifying
and Treating Young People with High-Risk Behaviors, and Teen Consent and Confidentiality. www.txhealthsteps.com
* Sexual Risk
Behaviors: HIV, STD, & Teen Pregnancy Prevention http://www.cdc.gov/HealthyYouth/sexualbehaviors/
FAMILY PLANNING / CONTRACEPTION
Parental consent
is not required for minors to purchase nonprescription contraceptives (e.g.,
condoms) or to receive information about family planning. Minors must get a
parent’s permission to receive prescription contraception*.
EXCEPTIONS
Under federal
law, minors may give their own consent and receive confidential family planning
services on request if the funding source is Medicaid or a Title X Family
Planning Program.
Under state law,
minors may consent for prescription contraceptives if they are legally
emancipated or 16 years old and living on their own. This does not include
abortion.
Notes: Several state and federally funded programs provide family planning
services. A locator for family planning providers in Texas is available online at
www.healthytexaswomen.org. For more information on minor consent related to family planning, see
the Texas Health Steps Online Provider Education module titled Teen Consent and Confidentiality. www.txhealthsteps.com.
*For state-funded
programs, providers may provide family planning services, including
prescription drugs, without the consent of the minor’s parent, managing
conservator, or guardian only as authorized by Chapter 32 of the Texas Family
Code or by federal law or regulations. When parental consent is required, the
parent must sign both the general consent for treatment and the method-specific
consent for a prescription method of contraception. Whenever the method is
changed to another prescription method, the parent must sign that
method-specific consent. Other than the exceptions noted above, no state funds
may be used to dispense prescription drugs to minors without parental consent.
RIGHTS WHEN PREGNANT
Minors can
consent to medical treatment related to pregnancy, other than abortion.
Eligible young women can receive prenatal care from Medicaid or CHIP. Pregnant
young women have the right to refuse prenatal care. (Texas Family Code §32.003)
TITLE IX RIGHTS TO EDUCATION
Pregnant and
parenting students have the same rights to access school activities and special
services that temporarily disabled students have a right to access. These
include the right to:
Continue going to
school, take regular classes, and participate in school activities. This also
applies to individuals who have given birth or had an abortion.
Choose to attend
a special program for pregnant or parenting students. Such a program must offer
the same opportunities available at their regular school.
Decline to attend
a special program for pregnant or parenting students.
Be excused for
medically necessary absences due to pregnancy or childbirth.
Not need a
doctor’s note to continue going to school or engaging in activities, unless all
students must have one.
[Title IX,
Education Amendments of 1972 (Title 20 U.S.C. §§1681-1688)]
Note: Private schools that do not receive federal funds do not have to follow
Title IX.
For more
information on teen pregnancy, see the Texas Health Steps Online Provider
Education modules titled High Risk
Behaviors and Preconception and Prenatal
Health: Identifying and Intervening in High-Risk Behaviors (all modules
within the Preconception and Prenatal Health “suite” offer helpful information
regarding women’s health prior to becoming pregnant and during pregnancy). www.txhealthsteps.com
MINORS’ RIGHTS AS PARENTS
Minors may
consent to health and dental care for their children. Pregnant minors and minor
parents may receive health services. Minor parents may also receive public
assistance for their children.
HEALTHCARE/SOCIAL SERVICE PUBLIC ASSISTANCE
PROGRAMS:
See page 22 for eligibility requirements for
these programs.
•Texas Health
Steps (THSteps) - Comprehensive child preventive health services for children
from birth through age 20.
•Medicaid
Children’s Services (CCP) - Medically necessary diagnostic and treatment services.
•Case Management
for Children and Pregnant Women - Case management services for Medicaid-eligible
children and youth who have a health condition or health risk and
Medicaid-eligible, high-risk pregnant women of any age.
•Medical
Transportation Program (MTP) - Free transportation to the doctor, dentist, and
other covered Medicaid or Children with Special Health Care Needs (CSHCN)
Program services (such as to the drug store for medications).
•Children’s
Health Insurance Program (CHIP) - Health-care coverage for low-income children of
low-income families without private insurance and ineligible for Medicaid.
•Supplemental
Nutrition Assistance Program (SNAP) - Food assistance (formerly food stamp
program).
•Title V Maternal
& Child Health (MCH) Services - Title V MCH provides prenatal care,
preventive and primary child health care, case management for children from
birth to one year and high-risk pregnant women, as well as dental care for
children and adolescents and services to children with special needs.
•Women, Infants
and Children (WIC) - Nutrition education and counseling, nutritious foods, and
assistance accessing health care.
PARENTAL NOTIFICATION OF ABORTION
A physician may
not perform an abortion on an un-emancipated minor unless one of the two
situations described below exists (Texas Family Code §33.002):
The physician gives at least 48 hours’
actual notice, in person or by telephone, of his or her intent to perform the
abortion to a parent of the minor, a court-appointed managing conservator, her
guardian or receives an order issued by a court under Texas Family Code §§33.003 or 33.004.
THE PHYSICIAN PERFORMING THE ABORTION:
Concludes that,
on the basis of his or her good faith clinical judgment, a condition exists
that complicates the medical condition – a “medical emergency” as defined in
Texas Family Code §171.002
– of the pregnant minor and necessitates the immediate abortion of her
pregnancy to avert her death, or to avoid a serious risk of substantial and
irreversible impairment of a major bodily function; and
Certifies in
writing to the Department of State Health Services, provides notices as
required by Texas Family Code §33.0022
and certifies in the patient’s medical record that the medical indications
supporting the physician’s judgment exist.
Exception: A
minor can have an abortion without notification to or consent of one of her
parents, managing conservator, or guardian if she obtains judicial approval
(also known as a “judicial bypass”). More information on judicial bypass is in
the Glossary on page 25.
See information
in the publication “So You’re Pregnant. Now What?” regarding the laws on
abortion and judicial bypass. For more information on notification and consent
related to abortion, see the Texas Health Steps Online Provider Education
modules titled Teen Consent and
Confidentiality and Adolescent Health
Screening. www.txhealthsteps.com
TIPS FOR EFFECTIVE COMMUNICATION WITH ADOLESCENT PATIENTS:
Spend time
talking with the young person and his or her parent individually.
Make time also to
visit with the parent and young person together.
Encourage teens
to discuss confidential issues with their parents.
Use the
HEEADDSSS* psychosocial interview format: Home, Education, Employment,
Activities, Depression, Drugs, Safety, Sexuality, and Suicidality.
Ask patients
about their friends’ involvements in risky behavior: For example, “Do any of
your friends smoke or drink alcohol?”
Encourage
adolescents to share their knowledge about a proposed treatment with you before
giving them information.
Ask open-ended
questions.
For more
information on effective communication with adolescents, see the Texas Health
Steps Online Provider Education modules titled Teen Consent and Confidentiality, Culturally Effective Health Care and Motivational Interviewing. www.txhealthsteps.com
*HEEADDSSS:
Stephens, M.B. (2006). Preventive Health Counseling for Adolescents; American Family Physician 74(7):
1151-1156.
MENTAL HEALTH CRISIS
When a provider
suspects a mental health crisis, he or she must make every effort to obtain a
prompt mental health evaluation and any medically necessary information.
Emergency
Referrals:
Suicidal
thoughts, threats, or behaviors
Homicidal
thoughts, threats, or behaviors
Resources:
Local
police/sheriff or other law enforcement officials or 9-1-1
Local emergency
room or psychiatric hospital
Local Mental
Health and Substance Abuse Center / hotline or Mental Health Crisis Center /
hotline. Local information can be found by dialing 2-1-1 or searching online at
www.211texas.org
Local Mental
Health Authorities (LMHAs) provide outpatient services. Statewide online
locator for LMHAs can be found at http://www.dshs.texas.gov/mhservices-search/
(Texas Health and
Safety Code §572.001; Texas Family Code §32.004)
Minor Consent:
Youths age 16 or
older, or one younger than 16 who is/has been married, may give consent when
requesting admission to an inpatient mental health facility by filing a request
with the administrator of the facility.
Minors may
consent for counseling for suicide prevention.
VIOLENCE
Professionals
must immediately report abuse if the victim is under 18 years of age.
Professionals should also encourage the young person to seek help, and they
should share information about victim service providers. See below for “Requirements for Reporting Abuse and Neglect”.
DEFINITIONS:
Dating Violence:
An act by one
person against another person with whom there is a dating relationship, and the
act is intended to result in physical harm, bodily injury, assault, or sexual
assault.
A threat that
reasonably places the individual in fear of imminent physical harm, bodily
injury, assault, or sexual assault.
Family Violence:
An act by a
member of a family or household against another family or household member that
is meant to result in physical harm, bodily injury, assault, or sexual assault.
A threat that
reasonably places a family member in fear of imminent physical harm, bodily
injury, assault, or sexual assault.
(Texas Family
Code §71.0021)
For more
information on reporting abuse, see the Texas Health Steps Online Provider
Education module titled Teen Consent and
Confidentiality. Also available is the Interpersonal
Youth Violence module. www.txhealthsteps.com
REQUIREMENTS FOR REPORTING ABUSE &
NEGLECT
A professional
who has reason to believe a minor’s health and safety may be affected by abuse
or neglect must report the case to a local law enforcement agency or to the
Child Protective Services (CPS) Division of the Texas Department of Family and
Protective Services within 48 hours of when he or she first suspects that the
child has been or may be abused or neglected. A professional may not delegate
to or rely on another person to make the report. (Texas Family Code §261.101)
EXAMINATION OF ABUSE OR NEGLECT WITHOUT
CONSENT
A physician,
dentist, or psychologist having reasonable grounds to believe that a minor’s physical or mental condition has been
adversely affected by abuse or neglect may examine the minor without the
consent of the patient, the patient’s parents, or other person authorized to
consent to treatment. (Texas Family Code §32.005)
Exception: Unless consent is obtained as otherwise
allowed by law, a physician, dentist, or psychologist may not examine a child
16 years old or older who refuses to consent or for whom consent is prohibited
by a court order.
REPORTING TO CPS
Phone:
800-252-5400; Fax: 800-647-7410; Website: www.txabusehotline.org Reports made through the website take up to 24 hours to process.
Note: HHSC and DSHS have established policies for child abuse screening,
documenting, and reporting policy for Medicaid contractors or providers. Refer
to the current Texas Medicaid Provider Procedures Manual, Provider Enrollment and Responsibilities Handbook for additional
information on reporting child abuse and neglect. The manual is updated monthly
and available online at the Texas Medicaid Healthcare Partnership (TMHP)
website. www.tmhp.com
STATUTORY DEFINITIONS FOR ABUSE &
NEGLECT
Abuse is defined
by Texas law as:
Mental or
emotional injury to a child.
Causing or
permitting a child to be in a situation in which the child sustains mental or
emotional injury.
Physical injury
that results in substantial harm to the child or the genuine threat of
substantial harm from physical injury to the child. This excludes an accident
or reasonable discipline by a parent or guardian.
Failure to make a
reasonable effort to prevent an action by another that results in physical
injury and substantial harm to the child.
Sexual conduct
harmful to a child’s mental, emotional, or physical welfare, including
continuous sexual abuse of a young child, indecency with a child, sexual
assault, or aggravated sexual assault as defined by the Texas Penal Code.
Failure to make a
reasonable effort to prevent sexual conduct harmful to a child.
Compelling or
encouraging a child to engage in sexual conduct as defined by the Penal Code.
Causing,
permitting, encouraging, engaging in, or allowing the photographing, filming,
or depicting of the child in obscene or pornographic material.
Current use of a
controlled substance in a way or to the extent that it results in physical,
mental, or emotional injury to a child.
Causing,
expressly permitting, or encouraging a child to use a controlled substance.
Causing,
permitting, encouraging, engaging in, or allowing a sexual performance by a
child.
Neglect includes
the following acts or omissions:
Leaving a minor
in a situation where he or she would be exposed to substantial risk of physical
or mental harm without arranging for necessary care for the minor and a
demonstration of an intent not to return by a parent, guardian, or managing or
possessory conservator.
Placing the minor
in or failing to remove him or her from a situation that a reasonable person
would realize requires judgment or actions beyond the minor’s level of
maturity, physical condition, or mental ability and that results in bodily
injury or a substantial risk of immediate harm to the minor.
Failing to seek,
obtain, or follow through with medical care for the minor, with the failure
resulting in or presenting a substantial risk of death, disfigurement, or
bodily injury or with the failure resulting in an observable and material
impairment to the growth, development, or functioning of the minor.
Failing to
provide the minor with food, clothing, or shelter necessary to sustain the
minor’s life or health, excluding failure caused primarily by financial
inability unless relief services had been offered and refused.
Placing the minor
in or failing to remove the minor from a situation in which he or she would be
exposed to a substantial risk of sexual conduct harmful to the minor.
Failure by the
person responsible for a minor’s care, custody, or welfare to permit the minor
to return to his or her home without arranging for the necessary care after the
minor has been absent from the home for any reason.
(Texas Family
Code §261.001)
REQUIREMENTS FOR REPORTING UNLAWFUL SEXUAL
CONTACT
A professional
must report nonconsensual sexual contact with an unmarried minor under the age
of 17 within 48 hours to CPS or local law enforcement. Texas Penal Code §21.11
states that a person commits an offense if, with a child younger than 17 years
and not the person’s spouse, whether of the same or opposite sex, the person:
Engages in sexual
contact with the child or causes the child to engage in sexual contact; or
With intent to
arouse or gratify the sexual desire of any person, the actor exposes the
person’s anus or any part of the person’s genitals, knowing the child is
present, or causes the child to expose the child’s anus or any part of the
child’s genitals.
STATUTORY DEFINITION OF SEXUAL CONTACT
Per Texas Penal
Code §21.011, “sexual contact” means the following acts, if committed with the
intent to arouse or gratify the sexual desire of any person:
Any touching by a
person, including touching through clothing, of the anus, breast, or any part
of the genitals of a child.
Any touching of
any part of the body of a child, including touching through clothing, with the
anus, breast, or any part of the genitals of a person.
Under §21.011 of
the Penal Code, an “affirmative defense to prosecution” related to minor sexual
contact may apply if the offender:
Was not more than
three years older than the victim and of the opposite sex?
Did not use
duress, force, or a threat against the victim at the time of the offense.
Has no history of
being a sex offender at the time of the offense.
Sexual activity
with a child under the age of 14 years is against the law and has no defense.
Note: Professionals are not expected to know all of the facts of an incident
or make a legal determination on whether it is a crime or there is a defense to
the crime before reporting possible abuse. For more information on reporting
unlawful sexual contact, see the Texas Health Steps Online Provider Education
module titled Teen Consent and
Confidentiality. www.txhealthsteps.com
Resources:
ELIGIBILITY REQUIREMENTS FOR
HEALTHCARE/SOCIAL SERVICE PROGRAMS
Case Management for Children and Pregnant
Women:
- Medicaid-eligible
children from birth through age 20 with a health condition/health risk
- Medicaid-eligible
women of any age with a high-risk pregnancy
Children’s Health Insurance Program (CHIP):
- Children from
birth through age 18
- Texas resident
and U.S. citizen or permanent resident
- Age-based family
income qualifications
- Income too high
to qualify for Medicaid
Family Planning Services:
- Provided to women
and men
- Health assessment
including medical history and physical exam
- Follow-up for
routine, problem, and/or birth control supplies
- Lab testing–Pap
smears, STIs, HIV, diabetes, anemia, etc.
- STI and urinary
infection treatment
- Pre-conception,
genetic, infertility counseling and referral
- Pregnancy
testing, counseling, and referral
- Postpartum
evaluation
- Prenatal and
other medical referrals
- Community and
individual education
- Social services
referrals–jobs, housing, mental health, etc.
- Partner violence
screening and referral
- Natural family
planning
- Eligibility is
based on client income, family size, and residency
Medicaid:
- Children from
birth through age 18 (Once enrolled, child is eligible through age 20)
- Texas resident
and U.S. citizen or permanent resident
- Family income
qualifications
Medicaid Children’s Services (CCP):
- Children eligible
for Texas Health Steps with an illness or condition that requires medically
necessary diagnostic and treatment services
Medical Transportation Program (MTP):
- Be enrolled in
Medicaid or Children with Special Health Care Needs Services Program
- Have no other
means of transportation to a medically needed service or benefit
Supplemental Nutrition Assistance Program
(SNAP):
- Families with
gross income at or below 130 percent of Federal Poverty Level (per family size)
- Categorical
Eligibility: If all household members receive or are authorized to receive
Supplemental Social Security Income (SSI) or Temporary Assistance for Needy
Families (TANF), the household is eligible for SNAP, if qualified under special
conditions
Texas Health Steps (THSteps):
- Medical and
dental services and case management for children from birth through age 20 who
have Medicaid
- Title V Maternal
and Child Health Services:
- Prenatal care,
preventive and primary child health-care, case management for children from
birth to one year and high-risk pregnant women, and dental care for children
and adolescents
- Eligibility:
Texas residents with family incomes less than 185 percent of the federal
poverty level who are not eligible for Medicaid or covered by CHIP
Women, Infants and Children (WIC):
- Pregnant women of
any age
- Women who are
breastfeeding a baby under one year of age
- Women who have
had a baby in the past six months
- Parents,
stepparents, guardians, and foster parents of infants and children under the
age of five can apply for their child
HEEADDSSS INTERVIEW SCREENING TOOL:
H – Home
Who lives with
the young person? Where?
Do they have
their own room?
What are
relationships like at home?
Ever
institutionalized? Incarcerated?
New people in
home environment?
Recent moves?
Running away?
What do parents
and relatives do for a living?
E – Education and Employment
School or grade
performance-any recent changes? Any dramatic past changes?
Favorite subjects-worst
subjects? (include grades)
Future education
plans?
Any current or
past employment?
Future employment
plans?
Relationships
with teachers-school attendance?
Any years
repeated or classes failed?
Suspension,
termination, dropping out?
Relationships
with employers-work attendance?
E – Eating and Exercise
Body image?
Has youth
experienced over/under eating when stressed?
In general, what
is the diet like?
Use of laxatives,
diuretics?
Induced vomiting?
Dietary
restrictions to control weight?
Excessive
exercise?
A – Activities
On own, with
peers-what do you do for fun? Where? When?
With family?
Sports-regular
exercise?
Church
attendance, clubs, projects?
Does young person
have a car, use seat belts?
Hobbies-their
activities?
Reading for fun-what?
TV-how much
weekly? Favorite shows?
Favorite music?
History of
arrests / acting out / crime?
D – Drugs
Use by peers? Use
by young person? (talk about alcohol, tobacco, and other drugs)
Use by family
members?
Amounts,
frequency, patterns of use or abuse, and car use while intoxicated?
Source-how paid
for?
D – Depression
Sleep disorders?
(usually induction problems, also early or frequent waking or greatly increased
sleep and complaints of increasing fatigue)
Appetite or
eating behavior changes?
Feelings of
boredom?
Emotional
outbursts and highly impulsive behavior?
History of
withdrawal or isolation?
Hopeless or
helpless feelings?
S – Safety
Domestic
violence?
Relationship violence?
Gun availability?
Seat belt use?
S – Sexuality
Degree and types
of sexual experience and acts?
History of
pregnancy or abortion?
Sexually
transmitted diseases-knowledge and prevention?
Contraception?
Frequency of use?
Need for barrier
contraceptive use?
History of sexual
or physical abuse?
Number of
partners?
Masturbation?
(normalize)
Orientation?
Comfort with
sexual activity, enjoyment or pleasure obtained?
S – Suicidality
Hopeless or
helpless feelings?
History of past
suicide attempts, depression, psychological counseling?
History of
suicide attempts by family or peers?
Decreased affect
on interview, avoidance of eye contact, depression posturing?
History of
recurrent serious accidents?
Psychosomatic
symptomology?
Suicidal
ideation? (including significant current and past losses)
Preoccupation
with death? (clothing, media, music, art)
GLOSSARY
Confidentiality: Confidentiality is the obligation of the
health-care provider not to disclose information. Except as permitted by law, a
provider is legally required to maintain the confidentiality of care provided
to a minor. Confidential care cannot be assured when the law requires parental
notification or consent or when the law requires the provider to report health
information, such as in the cases of contagious disease or abuse.
Consent: The legal doctrine of informed consent for health care is an agreement
to a recommended treatment when the consenting person is in possession of all
of the facts relevant to the decision and potential consequences. Consent must
be voluntary and not just represent acquiescence. Consent must also be
rational, that is, given by an intellectually competent individual with the
sufficient cognitive ability to make a decision. Emancipation: A minor may obtain legal
emancipation when a judge is convinced that the minor can take care of himself
or herself and be treated as an adult.
HIPAA: The Health Insurance Portability and Accountability Act (HIPAA)
requires the establishment of national standards for electronic healthcare
transactions and national identifiers for providers, health insurance plans,
and employers. It also contains provisions that address the security and
privacy of health data.
Judicial Bypass: A minor can have an abortion without
notification to and consent of one of her parents, managing conservator, or
guardian if she obtains judicial approval (also known as a “judicial bypass”).
To receive a bypass, a minor must file an application for a court order
authorizing her consent to an abortion without notification in the minor’s
county of residence. The application must 1) be made under oath; 2) include
statements that the minor is pregnant, unmarried, under 18 years of age, not
had her disabilities removed, wishes to have an abortion without notification
and consent of a parent, the minor has or has not retained an attorney, the
minor’s current residence, and include a sworn statement from the minor’s
attorney. The court enters an order authorizing the minor’s consent if the
hearing judge determines that she meets at least one of the required grounds
for approval. The process and requirements for obtaining judicial approval are
detailed in Texas Family Code §33.003. The pregnant minor must appear before
the court in person and may not appear using video-conferencing, telephone, or
other remote electronic means. The court shall enter an order authorizing the
minor’s consent if the hearing judge determines, by clear and convincing
evidence (described in Texas Family Code §101.007) that she meets at least one
of the following grounds:
She is mature and
sufficiently well-informed about her pregnancy options to make the decision
without notification and consent of a parent or legal guardian.
The notification
and attempt to obtain consent is not in the best interest of the minor.
The Court may
consider all relevant factors including if the notification and consent of her
parent or guardian could lead to physical, sexual, or emotional abuse.
The law
stipulates that the court shall rule on the minor’s application by 5 p.m. on
the fifth (5) business day after the date the application is filed with the
court, unless the minor requests an extension. In this case, the ruling must be
made by 5 p.m. on the fifth
(5) business day
after the date the minor states she is ready to proceed to a hearing.
If the court
determines that judicial approval should not be granted, the minor may
re-submit an application to the same court if the minor shows there has been a
material change in circumstances since the denial was issued. (Texas Family
Code §33.003) For specific guidance, please refer to the Judicial Bypass
process; So You’re Pregnant. Now What? in References.
Legal Guardian: Guardianship is a legal designation that
places the rights, safety, well-being, and legal choices of a person into the
hands of another. Guardianship is conferred on a relative, friend, guardianship
program, or private professional guardian by a judge’s decision that a person
is deemed incapacitated. The definition of an “incapacitated person” under the
Texas Probate Code includes minors.
Managing Conservators: A court-appointed, non-parental, sole
managing conservator must be a competent adult, an authorized agency, or a
licensed child-placing agency.
A parental sole
managing conservator (custodial parent) is court-appointed when the parents are
or will be separated or divorced.
If a managing
conservator is appointed, the court may appoint one or more possessory
conservators (non- custodial parent and/or person).
Minor: In Texas, the legal definition of a minor is a person under 18 years of
age who has never been married and never been declared an adult by a court.
Title V: As applicable in this guidebook, the general goal of Title V of the
Social Security Act - Maternal and Child Health Services Block Grant - is to provide
and to assure mothers and children (in particular those with low income or with
limited availability of health services) access to quality maternal and child
health services.
Title IX: Title IX forbids that any person, on the basis of sex, be excluded from
participation in, be denied the benefits of, or be subjected to discrimination
under any education program or activity receiving federal financial assistance.
The legislation covers all educational activities and complaints under Title IX
alleging sex discrimination in fields, such as science or math education, or in
other aspects of academic life, such as access to health care and non-sport
activities, such as school band and clubs.
It applies to an
entire school or institution if any part of that school receives federal funds.
Title X: Title X is the only federal grant program dedicated solely to providing
individuals with comprehensive family planning and related preventive health services.
The Title X program is designed to provide access to contraceptive services,
supplies, and information to all who want and need them. The law gives priority
to persons from low-income families.
Title XX: The Social Services Block Grant, or Title XX of the Social Security
Act, consolidated federal assistance to states into a single grant. Each state
determines how its Title XX funds will be used. While Texas uses no state
funding streams to provide for family planning services, it does allocate a portion
of its Title XX funds to pay for family planning services to low-income
individuals.
REFERENCES
American Academy
of Pediatrics, Committee on Bioethics (1995; 2007) Informed consent, parental
permission, and assent in pediatric practice (Pediatrics, 116, 1238-1244)
American Academy
of Pediatrics, Committee on Pediatric Emergency Medicine (2003; 2007); Consent
for emergency medical services for children and adolescents (Pediatrics, 111
(3), 703-706)
HEEADDSSS
Interview Screen: Stephens, M. B. (2006); Preventive Health Counseling for
Adolescents (American Family Physician 74(7): 1151-1156)
Texas Behavioral
Health Clearinghouse https://sites.utexas.edu/tiemh/2015/07/10/texas-behavioral-health-clearinghouse/
Social Security
Online www.socialsecurity.gov
“So You’re
Pregnant, Now What?” - DSHS publication for young people to understand the laws
associated with abortion and the judicial bypass process. It is a legislatively
mandated document and available for order from http://hhsc.pinnaclecart.com/dshs/.
Society for
Adolescent Health and Medicine http://www.adolescenthealth.org/Clinical-Care-Resources.aspx
Texas Family Code
Texas Health and
Human Services Commission, Your Texas Benefits website: https://www.yourtexasbenefits.com/ssp/SSPHome/ssphome.jsp
Texas Health
& Safety Code
Texas Health
Steps Provider Education Modules at www.txhealthsteps.com:
- Adolescent Health Screening
- Adolescent Substance Use
- Culturally Effective Health Care
- Identifying and Treating Young People with High-Risk Behaviors
- Interpersonal Youth Violence
- Mental Health Screening
- Teen Consent and Confidentiality
Texas Occupation
Code
Texas Penal Code
Publication 03-13584 Revised:
August 2016